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2 Introduction The complexity of the transition from a fully functioning hospital to an ambulatory care center should not be under-estimated. MLK closed its inpatient and its emergency services and had to reorder its operations to oversee ambulatory care nearly overnight. As will be addressed in other, more specific, HMA assessments and implementation plans that are being produced as elements of this contract with LA County, jobs and whole departments will be different. Some will need to be expanded and restructured and others down-sized or eliminated. Providers are in the process of transitioning from a mode of teaching and inpatient care to a total clinical ambulatory focus. An urgent care center is not an emergency room, a referral center that relied heavily on patients sent from the hospital now needs to related to a greater degree on its community partners, a scope of clinical services that used to be provided almost entirely within the institutions four walls now need to be assured through a network of other providers, accreditation and regulatory requirements (an intense focus of MLK over the past several years) are now completely different. All of these changes require new organization and accountability and skills and experience. HMA believes that this is transition is a difficult task but one that, if done right, offers the opportunity to create a new model that will integrate and direct efforts and resources at the clear need and demand in the communities and for the patient populations that surround MLK. In developing these recommendations, HMA has spent considerable time with the leadership of both the Department of Health Services (DHS) and Martin Luther King (MACC). Other organizational models from similar systems across the country were reviewed. In addition, however, we discussed the organizational structure and roles with other key stakeholders in the future of the MACC. Most importantly, we looked at critical relationships with other DHS institutional administrative and clinical leadership, including: Harbor-UCLA (for back-office functions and clinical coordination); LAC+USC (for its role in administering Hawkins); Rancho Los Amigos Medical Center (for its relationship with MLK in providing surgical services); High Desert MACC (for experience in making the transition that MLK is currently undergoing, and; Hubert H. Humphrey Comprehensive Health Center (for its critical role in delivering a full array of primary, specialty, diagnostic and urgent care services). Other key players (such as the Public Private Partner clinics with ongoing connections to MLK) were interviewed. As conclusions were reached, they were shared and discussed with the MLK leadership. What follows is HMA s assessment and recommendations on the evolution of a new organizational structure and processes that will, we believe, require six months to a year to fully implement but should be started now. The Concept of MLK Ambulatory Network

3 As was discussed in the HMA Staffing plan submitted in October of 2007, a key premise for the going forward of the MLK MACC must be the integration at every level with Hubert H. Humphrey Comprehensive Health Center (HHHCHC). There are several key reasons to formalize this integration it the organizational structure, including: HHHCH has experience in operating and receiving accreditation for an ambulatory facility. It has experience and expertise to share, both operationally and in clinical practice. The MLK MACC has become even more reliant on outside referrals (rather than most of its outpatients generated from its inpatient and emergency services). HHHCH has traditionally been the major non-mlk source for specialty and diagnostic referrals. Establishing even integration on assuring access and resolving real or perceived problems quickly takes on even greater import. The new MLK-MACC CNO and CMO have had significant experience with other DHS CHCs and will provide a solid linkage to and recognize the value of HHHCH. As budget pressures increase to become more effective and even to tailor clinical services around areas of increased specialty, it will be valuable for MLK to look at all of its related ambulatory services (clinical and administrative) and determine where it makes sense to consolidate and/or redirect resources. The organizational structure and processes described below address this inclusion of HHHCH at every level (nursing, administration, and medical staff)> Connection to MetroCare While the role of MetroCare (encompassing Harbor-UCLA and MLK) is different now than it was a year ago, the inter-relationship of the two institutions is still operationally and clinically quite profound. MLK relies on Harbor for most of its back office functions (finance, IT, plant and facilities, materials management, etc.). Further, as MLK no longer operates either an Emergency department or an acute inpatient service and also doesn t provide some outpatient specialty and diagnostic services, it must look to Harbor as its primary partner in assuring that the clinical loop is closed. For the most part, this connection appears to be informal and works better in some areas than others. This report will address specific ways to assure closer collaboration and accountability on both sides. Accountability Based on Measurable Benchmarks

4 The past two years have been difficult ones for everyone involved in MLK, from those that govern it (the Board of Supervisors), to those that oversee its management (DHS), to those that run day to day operations, to front line staff and providers. Most of all, it has been a difficult time for those patients who rely on MLK for their medical care. The focus of the organization now must be to chart a clear path (agreed to at every level) and set documentable benchmarks that address productivity, access to care, quality, effectiveness and, most importantly, improved community health status. These benchmarks cannot just be words. They need to be established by the institutional leadership, endorsed by DHS and held to by the Board of Supervisors. These benchmarks need to be tailored to every segment of the MLK workforce, from doctors to registration clerks. There must be a clear effort to disseminate the networks goals and report card on meeting those goals on a regular basis so everyone, particularly the community that MLK is to serve, sees that this is a new day. The organizational structure must not only set those goals but hold the institution accountable to meeting them. Ambulatory Specific Experience and Expertise This assessment does not address the expertise and appropriateness of individuals in organizational leadership at MLK. The HMA staffing study submitted in October does have job descriptions for key leaders based on this new ambulatory focus of the institution. Over the past few months, new leaders the CMO and CNO have been recruited and both have significant experience in the ambulatory setting. The only position that, we believe, is critical for the effective operations of an ambulatory network that includes both the MACC and a comprehensive health center and that hasn t been created is that of a COO. That job description is included because of its importance. Organizational Structure Organizational Charts The current organizational structure for MLK is based significantly on the remnants of the operation of a full service hospital. In particular, the many direct reports to the Administrator and the siloing of functions rather than creating integrated teams does not, in the long term, lend itself to cohesive and integrated planning and operations. HMA recommends, over a transitional process of about six months, that the following organization charts be implemented:

8 Medical Staff Administration The new CMO at MLK has moved quickly to address key operational and clinical priorities, many of which were raised in the HMA report in October. Organizational structure issues that should be prioritized in Medical Administration are: 1) Setting clear provider expectations for productivity benchmarks, for interaction with partner health care providers, for clear definition of scope of services to be provided within the network. 2) Standing weekly meetings with Clinical Leads, including the HHHCHC medical director, to review productivity across all service lines, receive and examine reports on waits for appointments and demand being unmet, identify and monitor specific areas that the providers take on for improvement, initiating more effective ways of providing care across the MACC and HHHCHC (like chronic condition management), etc. 3) A systematic effort should be made to have interaction with those providers (PPPs and others) who rely on the MACC for specialty care to both dispense information and to resolve concerns on either side. This should be a formal process and should alternate between MLK and one of the community providers locations. 4) The clinical relationship between the MACC and Harbor-UCLA should be more formally established, with monthly meetings to address both hand off issues and also planning for joint clinical initiatives. For example, jointly utilizing certain specialists, redirecting patients from one institution to another based on capacity, planning to meet growing specialty demand by maximally utilizing all resources at both institutions. 5) The current number and frequency of meetings and committees should be reviewed to assure that they are essential and productive. Many appear to be remnants of an inpatient institution. However, it may also be necessary to establish other committees and education functions focused on ambulatory care topics. 6) Over time, HMA believes that bringing the quality function under the CMO is appropriate and will go far in assuring an integrated approach to effective provision of health care services.

9 Nursing Administration The restructuring of Nursing Administration, transitioning from a hospital- to ambulatory-focus, is discussed at significant length in a separate HMA report. The transformation will be quite profound and will require significant energy and clear monthly benchmarks. Overall Organizational Priorities It will likely take some time (perhaps six months to a year) in order to make this streamlined organizational structure work, with the network functioning with a top leadership of four people in tune with the same goals and strategic directions. Now that there is a new CMO and CNO, both with ambulatory experience and expertise, the Administrator will need to recruit and hire a well-seasoned COO. It is clear that the clinical care can be top notch but if patient schedules are not developed within agreed upon guidelines, if ancillary services do not meet the clinical demand, if referrals are not made appropriately, etc. The priorities for organizational restructuring at MLK should be: 1) Hire a highly qualified COO. 2) Set organizational benchmarks and priorities for the next quarter, with clear areas of focus for each leader. Gain endorsement of those benchmarks and priorities from DHS and widely disseminate monthly assessments of progress. 3) Initiate the formal integration of management with HHCHC by: a. HHCH Medical Director reporting to MLK CMO (set benchmarks, jointly plan clinical priorities, disease management, specialty and diagnostic allocations); b. HHCHC CNO reporting to MLK CNO (potential for combining functions like quality, education, accreditation); c. HHCHC administrator reporting to MLK COO (emphasis on referral processes, set standards for staff allocation), and d. Establishing regular forum for interaction and planning and joint goal setting. 4) Establish MOU with Harbor-UCLA for all back office functions, clearly addressing the responsibilities for each institution. (This appears to have been

10 done successfully between MLK and LAC+USC describing expectations related to the operation of Hawkins). 5) Start now to plan for the future by: a. Establishing a planning team consisting of senior MLK/HHHCHC senior staff, representatives from PPPs, community b. Identify key health care access and health status issues impacting the community and its patient populations, targeting concerns raised by DHS annual SPA Community Assessments. c. Establishing targets for health status improvement. d. Designing scope of services to meet community demand.

11 MLK-Related Ambulatory Services Budget Title: Operations (COO) Pages: Attachments: Functional Title: Operations Job Code: Approved by: Senior Management Approved by: Administrator Effective Date: Salary Grade: MLK Ambulatory Services mission is to deliver integrated health services with dignity and respect regardless of a patient s ability to pay; to foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies which promote and protect the physical, mental and social well being of the people of cook County Written by: POSITION SUMMARY: The Operations serves as a senior administrative leader, supervising scheduling, registration, referral, health information management, ancillaries and support and social work managers as well as liaisons for functions performed by Metrocare: information systems, human resources, facilities management and security. Supervises administrative leadership of Hubert Humphrey Comprehensive Health Center and Dollarhide CHC to enhance operations among MLK-Related Ambulatory Services. Works with clinic leadership and all senior leaders to ensure effective operations at MLK-Related Ambulatory Services. As member of senior leadership team, participates in policy and budget preparation for MLK-Related Ambulatory Services. PRIMARY CUSTOMERS SERVED: MLK and MLK-Related senior administrators, medical directors, nursing leadership and patients. REPORTS TO: Administrator QUALIFICATIONS: Licensure and Certification California licensure in the areas of nursing, social work or other allied health fields preferred. Certification from an accrediting body in chosen field is desirable. Education Bachelor s degree required, Master s Degree in Health Care Administration, Nursing, Public Health or Social Work preferred. Age Specific Criteria: Environmental, Physical and Functional Requirements

12 Must be capable of travel to MLK-Related Services, DHS and PPP sites. Cultural Competence Must have cultural and linguistic skills appropriate for level of interaction with supervisees, colleagues, community groups and patients. Review Date: Revise Date: MLK Ambulatory Services Budget Title: Operations Budget Code: Functional Title: Operation SKILLS Must possess leadership and change management skills and have ability to impart these skills to managers. Must have analytical skills to define a challenge and support middle managers to formulate and evaluate a solution. Must be able to design, improve and evaluate workflows. Must be familiar with healthcare delivery in culturally and economically diverse communities. Must be proficient in health systems hardware and software applications and have a working knowledge of building maintenance and standards for health facilities. COMPETENCIES AND KEY ELEMENTS Competency Human Resources; Conflict Management; Budgeting/Financial Accounting; Resources Management; Cultural Competence; Analytical Assessment; Workflow Analysis; Statistical Analysis; Strategic Planning; Information Systems Healthcare Applications/Reporting; Communication; Community Health Partnering; Accreditation and Quality Improvement; Multidisciplinary Interventions. Key Elements 1. Supervises managers of MLK health clinics in areas of scheduling, registration, referrals, health information management and social work.

13 2. Provides local supervision of administrative functions reporting to Metrocare: information systems, human resources, facilities management and security. Maintains a collaborative relationship with these Metrocare departments. 3. Supervises administrator of Hubert Humphrey Comprehensive Health Center and Dollarhide Community Health Center to enhance operations among MLK-Related Ambulatory Services. 4. Assures adherence to MLK Ambulatory Services and DHS policies and procedures. 5. Assures availability of operational services, e.g. medical records, social services. 6. Conducts regular meetings with operations managers. 7. Works collaboratively with other members of MLK Ambulatory Services Senior Leadership Team on budget, operations, staffing and related problem solving issues. 8. Works with operational managers to assure maintenance of contracts and agreements for service. 9. Works with MLK and Metrocare centralized services to insure efficient work flow processes. 10. Works collaboratively with clinic leadership and Metrocare on renovation and building projects. 11. Represents MLK Ambulatory Services on DHS-wide committees as assigned. 12. Coordinates design and distribution of standard and ad hoc reports with information systems for MLK-Related Ambulatory Services. All job requirements listed indicate the minimum level of knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be construed as an exhaustive statement of duties, responsibilities or requirements.

14 Skills, knowledge, abilities Education, Experience Preferred Qualifications Minimum Qualifications Must possess leadership and change management skills and have ability to impart these skills to middle managers. Must have analytical skills to define a challenge and support middle managers to formulate a solution. Must be able to design, improve and evaluate workflows. Must be familiar with healthcare delivery in culturally and economically diverse communities. Must possess working knowledge of building design, maintenance and information systems. Bachelor s Degree Master s degree and required post-graduate training. License, Certification Licensure and certification in chosen field Special job characteristics requiring accommodations. List any features of the working conditions that Must be capable of travel to MLK-Related Ambulatory Service sites, DHS sites as well as related community meetings.

15 might require accommodation for an employee. This may include physical or other requirements such as travel, flexible work hours.

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